Dr. Kavita Patel, Brookings Institution and Bipartisan Policy Center

(Music)

Mark Masselli: This is a Conversations on Health Care I’m Mark Masselli.

Margaret Flinter: And I’m Margaret Flinter.

Mark Masselli: Well Margaret as expected congress led the deadline come and go,
st
March 1 deadline to reach a budget deal or let $85 billion in discretionary spending
cuts go into effect across the board and here we are.

Margaret Flinter: We are and what a challenge for the White House t o manage
expectations and reality on this one. Analyst are predicting that the budget sequ ester
could go on for weeks even for months and we have programs that are faced with I
think some very harmful cuts.

Mark Masselli: If you are listening to Health and Human Services Secretary Kathleen
Sebeliu s, she’s warning there are some (0:36 inaudibl e ) that will b e impacted in health
care.

Margaret Flinter: That’s right and her office s issued a report on the sequester cuts.
They predict that about 3000 fewer patients will be admitted for inpatient procedures
and maybe as many as 800,000 fewer outpa tient visits will be covered now that the
sequester cuts are coming through.

Mark Masselli: Well Medicaid and child health insurance programs are exempt from the
cuts, Medicare is not . The cuts could lead to a 2% reduction in Medicare
reimbursements for health practices which may not seems like a lot but it would be a
real hardship for practices in hospitals with high concentrations of Medicare patients.

Margaret Flinter: Well that’s right and remember many of these hospital s were also
looking at reduc tions at the state level so we can only wait and see what kind of
agreement may be reached. But speaking of physician reimbursement there’s a very
interesting report out this week, the national commission on physician payment reform
is urging an end to th e fee for service payment model in health care and in end to the
sustainable growth rate model for compensating physicians treated under the Medicare
payments, such big news.

Mark Masselli: It is and that’s an interesting report because it suggest a comp lete
over haul of the way public and private funds are used to compensate for health care
delivery and that unless these systemic problems are addressed we won't adequately
be able to address the cost containment issue s in health care.

Margaret Flinter: N ow , our guest today is well versed in another area of health care that
needs work. That’s the lack of a national program to adequately plan for the healthcare
workforce needs of the future in the United States.

Mark Masselli: Dr. Kavita Patel is Co - Chai r of the Bipartisan Policy Center, Professional
Workforce Initiative and we’ll discuss their recent report on ways to improve health care
workforce projections for the future.

Margaret Flinter: It’s actually very exciting, the work that they ’re doing. S he’ll be telling
us about their recommendations for creating a national system that better assist the
government, teaching hospitals, universities and school and the health professions to
build that skilled workforce that we need to meet the growing health care demands in
this country and to do it to a new model.

Mark Masselli: We’re getting here from our favorite friend Lori Robertson, Managing
Editor of Factcheck.org but no matter what the topic you can hear all of our shows by
googling CHC Radio.

Marg aret Flinter: And as always if you have comments, e - mail us at chcradio.com or
find us on Facebook or Twitter because we love to hear from you.

Mark Masselli: We’ll get to our interview with Dr. Kavita Patel in just a moment but first
here is our produc er Marianne O'Hare with this week’s headline news.

(Music)

Mariano Hare: I’m Marianne O'Hare with these the health care headlines. The budget
sequester is continuing through its first week with opposing members of congress
showing little will to shift their positions on budget reduction measures. In the mean
time automatic spending cuts are in effect across the board and they ’re starting to
impact health care coverage across the country. Community health centers are
expected to be particularly hard hi t. A study by the school of public health at George
Washington University projects 900,000 fewer patients will be treated at the nation’s
8000 community health center location s due to the automatic spending cuts. The
projections are based on $120 million and projected grant spending cuts to assist in
paying for that care. Meanwhile , politics are also impacting the Medicaid expansion call
for in the Affordable Care Act. Florida governor Rick Scott has joined a growing list of
GOP governors who switched e arlier positions refusing to expand Medicaid but the
Florida House Panel deciding the matter is signaling they won't go along with the
expansion of Medicaid to include a million more Floridians under the health care law.
That was opposing the expansion vo ted along GOP party lines .

And in a medical first, a baby born HIV positive in Mississippi has been cured according
to confirmed medical reports. The infant was heavily treated with retroviral drugs
beginning at 30 hours old, something that had not been tried before. This gives great
hope to those treating children with HIV and AIDS. 33 0 ,000 infants were infected in
2011 alone.

Need another reason to stick to your diet, starting next year under the health care law,
companies with 50 or more employers c an charge employee more for health care if they

don’t incorporate exercise into their preventive routine. Companies borrowing from the
biggest looser model are designing financial incentives to get their overweigh
employees to move more.

I’m Marianne O’H are with these health care headlines.

(Music)

Mark Masselli: We’re speaking today with Dr. Kavita Patel, Managing Director of the
Delivery System Reform and Clinical Transformation at the Engelberg Center for Health
Care Reform at the Brookings Institut ion. Dr. Patel is also Co - Chair of the Bipartisan
Policy Center , Health Professional Workforce initiative and co - author of two just
released reports, “The Complexit ies of National Health Care Workforce Planning” and
“Better Health Care Worker Demand Proje ction s ”. She worked in the Obama
administration as well a committee led by Senator Ted Kennedy in drafting of the
Affordable Care Act. She’s a practicing primary care physician at John Hopkins
University. Dr. Patel welcome to Conversations on Health Car e.

Dr. Kavita Patel: Thank you so much for having me in . Please call me Kavita.

Mark Masselli: Kavita, great. So we’re just months away from the implementation of
the Affordable Care Act in January 2014 and we’ll see tens of millions of uninsured
Ame ricans added to the system. So tell us a little bit about why workforce projections
are so complex in health care and why your reports are so important helping us
understand why the lack of relevant health care workforce data is leaving us ill equipped
to meet their coming needs.

Dr. Kavita Patel: Let me just start by telling you that when we were surprised sobering
to myself that when you look for supply estimates just how many health care
professionals we have in this country, you’ll find such variatio n from one store s to
another a nd it’s because of how we count health professional . So in some cases
physicians are counted only as primary care doctors and don't necessarily include the
specialist and then in some cases nurses are people with just an RN a nd but it if you go
to some of the nursing societies they also include people with RNs as well as other
advance d degree s like PhDs. And so there was such a wide variety of our estimates
that we saw okay we need to first do a deeper dive in what are the so urces o f data,
what are the differences in the sources of data and then we can start to talk about how
do we look at a model f or what kind of health care workers we might need or for
example the demand of health care. And it was -- as I mentioned very sob ering to try to
understand all the difference between some of these numbers which made it even more
complex.

Margaret Flinter: It seems to me Kavita that one of the challenges you have and I
thought you made this point really compellingly in one of your reports is that we keep
piling lots of new data on the top I mean you’ve made the case, we really have to

change the underlying assumptions if we want to make use of the new data, can you
talk a little bit more about that for our audience ?

Dr. Kavita Pate l: So let's just take a very basic example. A lot or our data assumptions
about what kind of workforce we need are modeled on our current system or old
systems of seeing patients in office visits and having always be a physician who leaves
that office vi sit and we also have used other assumptions about how many doctors you
need per thousand patients and we’ve use that model for years, in fact decades and in -
- all in the mean time we’ve since had all these new models of care patients that are
medical home s, accountable care organizations. We’ve seen a great proliferation of
community health workers, lay health workers, the use nurse practitioners and
physicians assistance in practices but our model and the way we think about how much
care we need still hi nges on this very cottage like industry with a doctor in charge.
Those are the assumptions we use when we start to say well there’s a shortage and I
think that that’s part of what we tried to tackle was wait a minute. Let's not just talk
about how we mig ht need one doctor for every you know 5000 people in the country .
Let's actually think about what kind of care do 5000 people need and then what are the
skill sets of the various members of the health care team that best suit those needs.
That’s almost f lipping the equation and saying what is it that we want to get to and how
do we work backwards to figure out what we need to fulfill that.

Mark Masselli: You know , you are seeing the fast rise of retail clinics, lot of different
ways that people are deli vering care and you really look at the distinction between
patient demand and true health care need. How are these needs differing in the
different socioeconomic groups as well?

Dr. Kavita Patel: We really thought long and hard about how you deal with e specially
the needs of high - risk populations take for example the 11 million Medicare dual eligible
and Medicare, Medicaid dual eligible for this country, really high concentration i s need .
A nd one thing that we found is that in modeling our demand sides that we talked about
supply a little bit and I kind of alluded to the demand, that’s where the information about
the sub populations really come s to play. What we found was that instead of looking at
those -- both the location or site of care, we really n eed to understand how could care
delivery to special populations look differently. We must agree on some standardized
data reporting and this means not just on the supply side but we have to have some
standardized reporting on the demand side especially f or populations and special
interest.

Margaret Flinter: On e area seems to me from working at the state level anyway is we
don’t have any uniformity across states in terms of the kind of data we collect, what's
your approach as a really a national research group looking at this, what's your
approach trying to get states to agree on how to collect data in common and
electronically and what the critical elements of data are to collect.

Dr. Kavita Patel: So this is a perfect question because we actually reac hed out to a
National Governors Association who has been very interested in this exact issue. What

are the minimum state data reporting requirements and we canvassed across the states
to try to understand what is it that they currently do and then how can we effectively give
them some recommendations and they are actually more than willing to adapt a little bit
more of a standard approach but I was surprised, people said look we a re a
overwhelmed, we have no idea what to do about this, we want you to tell us what to do.
So what we actually did is we went back and then went to our federal colleagues in the
health resources and services administration which is tasked with doing some of this
work and through the Affordable Care Act, we actually went back to t hem and said
listen , c an you tell us what you ’re coming up with in terms of minimum data elements
and how you are recommending those to be collected and then we will take those back
to the states and that’s exactly the process that we’re in right now. We’ re actually taking
what HERSA has been doing and recommending and saying to the states, we’re not
telling you, you have to do this, here’s what the federal government is trying to do,
here’s how we could recommend you do this and the timing could not be be tter because
they are already updating their data collection infrastructure to meet the needs of the
expanded Medicaid enrollment and health insurance exchanges . S o they ’re willing to
do this but they just need help I mean these are really great people in side the states
who are trying to do everything at the same time . S o we found that it was best to care
the work going on at the federal level and say here’s the minimum and health IT plays a
big role in this, we’re trying to explore right now, how to get the best, how we can try to
understand some health work force staffing information based on the health IT systems
that are currently deployed across the country.

Mark Masselli: We’re speaking today with Dr. Kavita Patel , Managing Director of the
Delivery System Reform and Clinical Transformation at the Engelberg Center for Health
Care Reform at the Brookings Institution . Dr. Patel served in the Obama administration
as the director of policy for the Office of Intergovernmental Affairs and Public
Engagement . So lots of exciting opportunities arise out of the Affordable Care Act, its
creat ed many new incentives and innovations in health care. It also created some new
challenges , you know what, through for our listeners s ome of those challenges and how
you t hink we might best meet them.

Dr. Kavita Patel: I do think we are really at a precipice of how can we leverage the data
that we have and then these emerging models of care and so one thing I would say is
that we walk through this as we’re thinking about restructuring care differently and we’re
thinking about trying to decrease the cost of health care and then we’re also looking our
patients in the eyes and saying you know what I ’m going to try to make sure that I give
you the best information in a small a mount of time as possible but I will also hope that
you take that information and make better decisions from it. So I see this is like a
narrative of a kind of a cycle, a life cycle, then we also have to look at some of these
e merging innovation models an d say what are we learning about the kinds of training,
the skill sets and the response from our patients and then how do we s ee that back. I
mean we have a massive infrastructure of education in your country and we don’t talk
about it a lot. We talk abo ut health reform a lot. We don’t talk about going in and
opening up our classrooms and saying wait a minute are we actually training the types
of people that we actually want on the receiving end and I would say to you there’s a

great disconnect there. S o I see this is a great life cycle in a true biological sense. We
need to cycle it back and I think that to me that’s the narrative and not just in this
workforce study but the Bipartisan Policy Center’s doing work on cost containment,
they ’re doing work on health IT. Those things have to marry together.

Margaret Flinter: You know the Affordable Care Act had a number of important
provisions that have not yet come to pass and I noted in your report, you addressed or
you listed one of them which we actual ly authored around the demonstration grants for
Family Nurse Practitioner Training Programs which are in there but not yet appropriate -
-

Dr. Kavita Patel: Funded.

Margaret Flinter: -- but funded but much larger than that really is the creation of the
national health care workforce commission that would have addressed this need for
more centralized data and I think probably would have gone at that connect ion between
education training not just a clinical care but to models of care and what's your
expect ation about what will happen with that national health care workforce
commission?

Dr. Kavita Patel: If I start getting bogged down in what congress can and can't do I ’ve
been just having worked on the inside it can get pretty depressing. I am optimistic that
all of the things we’re talking about and by the way I’m a fan of your program because I
think you all do a great job of bringing these complex concept to people in a very kind of
digestible way. I think everything you’ve been talking about for mont hs now quite
honestly is going to come to a head when we’ve got headlines in 2014 that say you
know in certain parts of the country, it’s hard to find a primary care doctor, et cetera, et
cetera and I think that’ll force the issue for people to say wait a minute we have this
provision in health reform, what happen to it ? A nd then we’re really talking about 2 to
$3 million for the workforce commission to be funded but in the big picture and the
impact it could have, it’s a great investment . S o I am optimis tic that in the next year
we’re going to see enough demand for the information that the commission will have. In
the mean time though we have go t to figure out how to leverage the private sector and I
know we say that a lot in health care but I am serious . We a re seeing the big insurance
companies, big integrated systems like Geisinger, Kaiser , we’re seeing them come
forwards with their own creative data set solutions, models of care and estimates, I
think we need to go back to some of these leaders in t he private sector and say listen
let's actually think about what the needs could be and what you can teach the rest of the
country in terms of what you found and then actually let's take that out and show how
states like Texas can think about Medicaid expa nsion and workforce models in a
different way.

Mark Masselli: I really liked it when you took us back to that big picture looking at the
triple aim of the Affordable Care Act to increase access, improve outcomes and reduce
cost and questioning how they c ome back to the educational system. So there’s other
so many different models happening and I just really worry that the education al system

in our leadership for that next generation of nurse practitioners, physicians assistants,
physicians, all the allie d health providers just are n’t ready for prime time and we a re at a
point of reinvention and redefinition of how primary care could operate in an optimal
setting, what should we be looking out for rays of hope from you?

Dr. Kavita Patel: Let me tell you that I always look for rays of hope in a lot of different
pair settings because often talk about you know Virginia Mason Group Health , Kaiser ,
they ’re incapacitated settings , they’ve got kind of a lovely bubble around them so to --
so I look for things tha t could actually take advantage of really amazing care in a fee for
service setting. Let me give you two examples in Medicare. One is a program in
Florida called ChenMed . They take care of pretty much a 100% Medicare patients and
they do it in Florida, one of our costliest states and they do the following. They send out
a town card to pick up patients and they do auto reminders for patients and these are
elderly patients. But we think the elderly don’t u se technology, they do with they’ve got -
-

Mark Masselli: Oh, yeah, absolutely.

Dr. Kavita Patel: -- grandchildren that they talk to on Skype and Facebook more than I
do. So they meet the needs of patients that generally costs the system a lot of money
but they meet the needs by dealing with things t hat don’t get reimbursed by Medicare
but what they found is they can actually make money, meaning they ’re not losing money
on this and they do this kind of wrap around and text reminders about preventive
services that are due and I think that that’s an ama zing accomplishment in the Miami
area. The second one I’ll tell you about is something you may have heard of because
he was profiled in one of a (18:37 inaudible ) as I say is Rushika Fernandopulle started
Iora Health and they take what you ’re talking abou t a little bit mark with kind of the pod
design but they take with the hot spotters and design a clinic around hot spotters ’
need s . And they ’re doing this in Massachusetts and Atlantic City, New Jersey and
they’ve just opened all in a Medicaid, Medicare s etting mostly dual eligible and they sat
and looked at what hot spotters needs are when they do come to clinic and they
basically structured an entirely different flow of work to address those needs. And so I
think that those are rays of hope because they ’re entrepreneurial, they ’re in our current
system which in a large way is somewhat broken financially but they ’re doing something
and they ’re making it work financially and what I hope is that I really want Rushika and
ChenMed to give us the data on how t hey’ve understood the staffing needs for their
health care and how we can actually go back to some of the top medical school s and
nursing schools and allied health workers schools in the country and say how are we
training people to engage and work in thes e environment.

Margaret Flinter: We’ve been speaking today with Dr. Kavita Patel, Managing Director
of the Delivery System Reform and Clinical Transformation at the Engelberg Center for
Health Care Reform at the Brookings Institution. Dr. Patel is also Co - Chair of the
Bipartisan Policy Center , Health Professional Workforce Initiative and the co - author of
just released reports, “The Complexit ies of National Health Care Workforce Planning”
and “Better Health Care Worker Demand Projection s ”. You can access these reports

and learn more about her work by going to by bipartisonplicy .org. Dr. Patel , thank you
so much for joining us today on Conversations on Health Care .

Dr. Kavita Patel: Thank you for having me.

( Music )

Mark Masselli: At Conversations on Health Care we want our audience to be truly in the
know when it comes to the facts about healthcare reform and policy. Lori Robertson is
an award winning journalist and managing editor of Factcheck.org , a nonpartisan,
nonprofit consumer advocate for vote rs that aim to reduce the level of deception in U.S.
politics. Lori, what have you got for us this week?

Lori Robertson: Well, Mark and Margaret , we received several questions from readers
about online reports that claim the IRS said the cheapest health insurance plan for
families under the Federal Health Care Law would cost $20, 000 b ut that’s not with the
IRS said at all. Instead this number comes from a hypothetical example in an IRS
document about how it would calculate the tax penalty for a family t hat doesn’t obtain
health insurance as required by the Affordable Care Act. A tertiary official told us that
the $20,000 figure was “ Not a n estimate of premiums ” . Like many viral claims this
figure was taken out of context and then embellished . The IRS wasn’t estimating the
cost of premiums at all. The fact is no one knows exactly how much insurance plans
sold on state and federal run exchanges will cost. Back in January 2010 , shortly before
the law was pass ed, the nonpartisan congressional budget offi ce estimated that the
cheapest plan would cost between $12,000 and $12,500 for family policies b ut CBO has
an update of that estimate since . CBO did say that about 80% of the 25 million people
getting insurance on these exchanges by 2023 will receive fede ral sub sidies to help
cover the cost a nd the average subsidy would be $8,290 for the year. For those who
are interested , the Kaiser Family Foundation has a subsidy calculator on its website that
gives the sense of who’s eligible for subsidies and how much those subsidies might be.
And that’s my factcheck for this week . I am Lori Robertson , Managing Editor of
f actcheck.org.

Margaret Flinter: Factcheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact that you’d liked checked e - mail us at
chcradio.com, we’ll have f actcheck.org’s Lori Robertson check it out for you here on
Conversations on Health Care.

(Music)

Mark M asselli: Each week conversations high lights a bright idea about how to make
wellness a part of our communities in everyday lives. When Jennifer Staple - Clark was
a sophomore EL in the internship at the ophthalmology office turned out to be a life
transfor ming experience. She realize d that many of the patients who had limited access
to medical care were coming into the office with serious eye conditions that had gone

pass the point of reversing leading t o unnecessary blindness. What she launch ed from
her dorm room 11 years ago was a local initiative to improve access to preventative eye
care to the neediest population in her local community. Her visio n quickly grew, within
two - year . S he took her organization Unite for Sight worldwide and has since turned it
into one of the leading providers of global eye care in hundreds of communities around
the world. Unite for Sight brings social entrepreneurs , public health experts , local eye
surgeons and volunteers together to bring eye care into some of the most un derserved
areas of the world. The motto at Unite for Sight is that local problems need local
solution, s o they use each country ’s existing pool of ophthalmologist to treat their local
patients. They also train community health workers in each area they s erve , that’s
removing traditional barriers and also ensur ing a continuum of care for all of the patients
they serve. The community health workers provide education and transportation to get
doctors to t he patient ’ s communities and patient to the hospital i f surgery is indicated.
Since its inception Unite for Sight has served 1.4 million patients worldwide and
re stored eye sight to roughly 55,000 people , re storing not only their sight but their
dignity and ability to be productive members of their communit ies as well. Identifying a
pressing medical need and improving the quality of life by offering basic preventative
eye care to those who ha d previously gone without now that’s a bright idea.

(Music)

Margaret Flinter: This is Conversations on Health Care , I’m Margaret Flinter.

Mark Masselli: And I’m Mark Masselli, peace in health.

Conversations on Health Care broadcast from the campus of WESU at Wesley
University streaming live at wesufm.org and brought to you by the community health
center.